Potentially Avoidable Hospitalizations Among Historically Marginalized Nursing Home Residents

Key Points Question What is the potentially avoidable hospitalization incidence rate among historically marginalized nursing home residents with and without severe cognitive impairment? Findings This cross-sectional study of 2 098 385 nursing home residents found that Black or African American and Hispanic nursing home residents with severe cognitive impairment experienced the highest incidence of potentially avoidable hospitalizations. Meaning These results suggest that efforts to reduce potentially preventable hospitalizations among nursing home residents should target Black or African American and Hispanic residents, especially those with severe cognitive impairment approaching the end of life.


Introduction
An estimated 70% of all people with severe cognitive impairment die in nursing homes (NHs), and more than half of NH residents have cognitive impairment. 1 Annually, 1 in 4 NH residents are hospitalized, which is associated with decline in cognitive function. 2Cognitive decline can progress from severe disability to dementia and ultimately death. 3ross the US, Black or African American older adults have the highest prevalence of severe cognitive impairment, followed by Hispanic older adults. 4Severe cognitive impairment typically indicates the individual is approaching the end of life (EOL) and is characterized by decline in function, purposeful movements, language abilities, and ability to recognize people. 4Notably, race and ethnicity are social constructs, not biological variables, and therefore a proxy measure of racism. 5storically marginalized residents (ie, American Indian or Alaska Native, Asian, Black or African American, Hispanic, Native Hawaiian, and Pacific Islanders) often enter the NH in poorer health and with more comorbidities than White residents, related to generational cycles of poverty, mistrust of health care practitioners and the health care systems, and experiences of racism and discrimination that have led to delayed care. 6,7][10][11][12][13] EOL care for individuals with severe cognitive impairment should be aligned with their goals of care, offered to ease symptom burden, and improve quality of life, which hospitalizations do not always do.
5][16] Potentially avoidable hospitalizations (PAHs) result from neglectful NH care or that which NH treatment would have been appropriate. 17Despite pervasive racial and ethnic inequities in NH care (eg, segregation and NHs with poor outcomes, 18 worse EOL care, 19 fewer palliative care services 20 ), limited knowledge exists about PAH racial and ethnic inequities in patients with severe cognitive impairment.The study objective was to identify racial and ethnic incidence rates for PAHs among all NH residents, with and without severe cognitive impairment, who are approaching the EOL.

Study Design, Setting, and Participants
The Columbia University institutional review board approved this cross-sectional study and waived the need for informed consent because the use of secondary data was not deemed human participants research.The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline was followed.The study sample included all NH residents with a long stay (>100 days) and aged 65 years and older who resided in an NH in the US in 2018 and experienced a hospitalization.Analyses were performed from January to May 2022.

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Potentially Avoidable Hospitalizations Among Historically Marginalized Nursing Home Residents these variables do not represent biological, cultural, or language differences between groups. 22,23e first MDS index assessment in 2018 was used to identify resident race and ethnicity, and if missing from MDS, was obtained from the MBSF using RTI race codes, which were created using an algorithm of US Census and geography. 24Residents with missing race or ethnicity were excluded from the analytic sample (n = 1004 [0.05%]).
Covariates included NH facility and resident characteristics.NH facility characteristics were obtained from LTCFocus and included size (ie, number of certified beds), chain status, and ownership of facility.Resident characteristics included: age, sex, dual eligibility (ie, Medicaid and Medicare coverage) in months, and chronic conditions, collected from the MBSF.Additionally, we controlled for resident time-at-risk exposure (ie, total time in NH for 2018 after the first index MDS assessment).
Severe cognitive impairment was measured on the cognitive function scale (CFS), which was designed for all NH residents and calculated by MDS assessments. 25The CFS is a valid tool for assessing resident cognitive assessment, 25 regardless of English language proficiency. 26It is a 4-level scale: cognitively intact (CFS = 1), mildly impaired (CFS = 2), moderately impaired (CFS = 3), and severely impaired (CFS = 4).A resident was considered to have severe cognitive impairment (ie, CFS = 4) on all assessments after these criteria were first met from the first quarterly MDS assessment. 27Residents with a missing CFS score were excluded from the sample

Statistical Analysis
Unadjusted and adjusted Poisson regression models with and without NH fixed effects were generated to estimate the incidence rate ratio (IRR) for PAHs across racial and ethnic categories.To account for arbitrary correlation structures among all observations within a US state, we calculated standard errors using block-bootstrap methods clustered at the state level. 28,29our separate models were developed.Model 1 was an unadjusted model with race and ethnicity only.Model 2 was the unadjusted model with race and ethnicity and NH fixed effects.
Models 1 and 2 provided information on unadjusted, crude PAH IRRs by race and ethnicity.Model 3 adjusted for resident and facility characteristics, and model 4 adjusted for resident characteristics and NH facility fixed effects.Adjusting for NH fixed effects allowed us to identify racial and ethnic differences that occurred within NHs.Comparing the models with and without NH fixed effects allowed us to determine the extent that differences were generated by variations within NHs vs between NHs.For example, if the IRR was 1.30 in model 1 and the corresponding within-NH IRR in model 2 was 1.15, then the 50% rate decrease ([15 / 30] × 100) indicates that half of the IRR difference is due to within-NH differences.
To investigate whether racial and ethnic differences in PAH rates differed by cognitive impairment, we estimated alternative versions of all models with an interaction term (race and ethnicity × severe cognitive impairment).Each hypothesis test was formally completed using a

Discussion
In this cross-sectional study, historically marginalized NH residents with severe cognitive impairment had greater PAH incidence compared with their counterparts without severe cognitive impairment.
Compared with White NH residents in unadjusted analyses accounting for NH fixed effects, American Indian or Alaska Native, Asian, Black or African American, and Hispanic residents with severe cognitive impairment had significantly greater PAH incidence compared with White residents.
Increased prevalence persisted across all analyses for Black or African American and Hispanic residents.

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Potentially Avoidable Hospitalizations Among Historically Marginalized Nursing Home Residents Although disturbing, the greater PAH incidence observed among historically marginalized residents is not surprising.Regardless of cognitive impairment status, the greatest PAH incidence rates were consistently found among Black or African American residents.It is important to highlight that PAHs may result from neglectful care. 15Longstanding inequities in health care and unfair practices across structures and policies have resulted in cycles of disadvantage for historically marginalized populations. 30,31Historically marginalized residents with severe cognitive impairment have an even higher risk.They may have limited language abilities, which can potentially lead to worse care, poor recognition of distress, higher illness burden, and worsening symptoms that result in PAHs.Overall, the greater PAH incidence rates among historically marginalized residents were often explained by differences within NHs.These results suggest that regardless of which NH the resident resides in, American Indian or Alaska Native, Asian, Black or African American, and Hispanic residents with severe cognitive impairment have greater PAH incidence.6][37] NHs are often segregated, racial disparities are pervasive, and structural racism are all known factors that have led to these inequities in NH care. 18r findings suggest that early identification and monitoring of cognitive impairment may be crucial to improving EOL care outcomes, particularly for American Indian or Alaska Native, Black or African American, and Hispanic residents for 3 reasons.First, we found that residents without severe cognitive impairment had lower PAH incidence compared with residents with severe cognitive impairment.Early identification of cognitive impairment can reduce PAHs given the known associations between cognitive decline and hospitalizations. 2 Particularly for residents with cognitive impairment, monitoring, early identification, and timely follow-up to prevent or manage the condition in the NH as medically appropriate should occur to avoid escalation of the underlying condition and unnecessary hospitalization.Second, given that American Indian or Alaska Native, Asian, Black or African American, and Hispanic residents with severe cognitive impairment had higher incidence rates of PAHs compared with White residents, careful monitoring of cognitive function before and after hospitalizations may prevent further escalation.Notably, we found that Asian residents were more likely to have cognitive impairment, which is inconsistent with some community-based samples. 38However, comparisons with prior work are limited because of differences in sample characteristics (eg, included small Japanese and Korean American populations) 38 while we had a representative nationwide sample.Third, finding that historically marginalized NH residents with severe cognitive impairment have greater PAH incidence provides evidence for future research interventions to reduce EOL PAHs and achieve health equity for historically marginalized NH residents.Residents with severe cognitive impairment, as with others with serious illness, should have EOL care that upholds resident and family values and wishes, and efforts to describe and document preferences and implement goal concordant care should be executed before cognitive and physical decline. 39ven the high rate of cognitive impairment among NH residents, PAHs are naturally more common for individuals with cognitive impairment, which highlights the importance of our findings.We found that American Indian or Alaska Native, Asian, Black or African American, and Hispanic residents had greater PAH incidence compared with White NH residents.Black or African American and Hispanic residents often have delayed diagnosis, 40 and cognitive impairment prevalence and diagnosis has been understudied among the American Indian or Alaska Native population. 41Unfortunately, this might imply that more residents of these populations have severe cognitive impairment than are reported and, as a result, actual incidence rates for PAHs may be underestimated.
The EOL experience is individualized and the primary goal for better outcomes is to provide person-centered, family-oriented care, and provide comfort. 42PAHs are not consistent with these goals.An important component for EOL care in NHs is the integration of palliative care.Palliative care is medical care for individuals with serious illness and their families, such as NH residents, focused on improving quality of life through relief of symptoms and stress related to illness, regardless of prognosis. 43lliative care has the potential to reduce inequities in NH care, particularly at the EOL for historically

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Potentially Avoidable Hospitalizations Among Historically Marginalized Nursing Home Residents marginalized NH residents, by providing patient-centered care.The integration of palliative care and advanced dementia care has been shown to improve symptom management for persons with dementia in community settings. 44,45In a study of 31 NHs, palliative care consultations for residents with moderate to severe dementia reduced hospitalizations for residents in the days prior to death. 46Recent national initiatives from the CMS Innovation and the Medicare-Medicaid Coordination Office have aimed to reduce NH PAHs, but none were specific to palliative care. 47These initiatives are often focused on equality, which provides the same resources for all NHs, instead of focusing on equity, which prioritizes need. 48Indeed, wide variation in NH palliative care services nationwide has been identified, 49 and disturbingly, NHs with increased concentration of Black or African American or Hispanic residents have fewer palliative care services. 31Given our results identifying differences both between NHs and within NHs, further examination is warranted regarding the association of PAHs and palliative care services for historically marginalized NH residents.

Limitations
This study has limitations that must be acknowledged.First, the nonrandomized design prevents causal interpretations of the results.Second, the MDS data are subject to self-reporting biases from staff.However, these data are federally regulated and found to be both valid and reliable. 50Third, although we controlled for the resident's time of residence in the NH during the year 2018 (ie, time at risk), our ability to account for the total resident time at risk was limited, which would require longitudinal data.However, given the validity and reliability of the nationwide datasets used, we are confident that these findings accurately represent racial and ethnic PAH incidence rates for historically marginalized NH residents compared with White NH residents.

Conclusions
This study has important implications for NH residents with severe cognitive impairment.Higher PAH incidence rates were observed across all historically marginalized residents compared with White residents, and especially for American Indian or Alaska Native, Black or African American, and Hispanic residents with and without severe cognitive impairment, despite national initiatives to reduce these hospitalizations.Although our findings suggest that the PAH incidence differences were explained by both between-NH factors and within-NH factors, a large fraction of the total difference was explained by within-NH differences, which may be related to a combination of experiences with racism and discrimination.Future research should examine how palliative care can reduce PAHs, specifically for historically marginalized residents with severe cognitive impairment.
and assessment health status tool in CMS-certified NHs.MEDPAR is a CMS dataset of inpatient hospital claims.The MBSF is a CMS dataset describing all Medicare beneficiaries in a calendar year.LTCFocus is a publicly available, NH facility-level dataset derived from various datasets including the MDS, the Certification and Survey Provider Enhanced Reports systems, Medicare claims, and NH Compare.21 JAMA Network Open.2024;7(5):e249312.doi:10.1001/jamanetworkopen.2024.9312(Reprinted) May 2, 2024 2/11 Downloaded from jamanetwork.comby guest on 05/04/2024 a standardized screening 2-tailed test with α = .05as the statistical significance threshold.All statistical analyses were performed in Stata version 17 (StataCorp) from January to May 2022.

Table 1 .
Characteristics of Nursing Home Residents a P values calculated using ANOVA and Pearson χ 2 tests where applicable.Significance level is α = .05. b Represented in row percentages.c Represented in column percentages.

Table 2 .
Unadjusted Analyses of Potentially Avoidable Hospitalizations Incidence b Race and ethnicity, the independent variables of interest, are the interaction terms of race and ethnicity × severe cognitive impairment.They are presented by severe cognitive impairment status and race and ethnicity.cSevere cognitive impairment defined as cognitive function score = 4.

Table 3 .
Multivariable Analyses of Potentially Avoidable Hospitalization Incidence b Race and ethnicity, the independent variables of interest, are the interaction terms of race and ethnicity × severe cognitive impairment.They are presented by severe cognitive impairment status and race and ethnicity.cSevere cognitive impairment defined as cognitive function score = 4.